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Table 2 Summary of progress, barriers, facilitators, and future directions for nine recommendations to support the implementation of WHO guideline on the prevention and treatment of PPH as identified by participants

From: Navigating barriers: two-year follow up on recommendations to improve the use of maternal health guidelines in Kosovo

Recommendation Progress to date Barriers Facilitators Possible future directions
#1: Create a centralized system for data collection across clinical setting as well as for formal and informal channels for practice sharing. Centralized system for data collection
• Although a centralized system has not been developed, preliminary steps to formalize the system are underway.
• Piloted efforts to consolidate all institutions in improving data collection processes:
o Equipment installed in Prizren Regional Hospital a year ago is not yet functional;
o 7 FG discussions have been conducted to facilitate the process for designing relevant software for this system.
• Established a health information system using intranet, which is used for data collection at local hospitals/family medicine centres. There is no consistent data reporting process.
• Until full implementation of the directives outlined by MOH in the Strategy of Information 2010–2019 is completed, local level data is being collected through different sources (e.g., charts, registers, reports to the National Institute of Public Health).
Practice sharing
• The Mother, Child and Reproductive Health Office, MOH with technical support from UN agencies organized coordination meetings in which all stakeholders involved in maternal and child health gather to discuss progress or barriers and share individual experiences.
• Key informant mentioned taking steps to engage in practice sharing through coordination meetings.
Centralized system for data collection
• No barriers reported by participants.
Practice sharing
• Meetings lack a person with decision-making power.
• Lack of buy-in from stakeholders.
Practice sharing
• These meetings were held frequently, but have become less frequent recently.
• Stakeholders involved in these meetings do not have any decision-making power, they can only advocate, voice their concerns and recommendations.
Centralized system for data collection
• Implementing the information strategy by creating a centralized data collection system is a priority of the Secretarial Health Strategy 2014–2020 and is supported by other international projects.
Practice sharing
• Working groups developed to share information are attracting the right people (i.e. MOH, leaders in maternal health).
Centralized system for data collection
• Local data collection initiatives are perceived to have been effective in yielding usable data (e.g., Annual Health Statistics 2013).
• Participants believe that once the centralized system is operationalized and national level data is in electronic format, it will provide an adequate view of mortality and fatality and help select and prioritize topics for guideline development.
Practice sharing
• A key informant suggested that the MOH officially endorse these meetings, and use them as a basis for creating an official body with adequate representation from key institutions and decision-making authority.
#2: Incorporate standards into clinical practice including a monitoring system for guideline adherence. • Although standards and protocols have been developed, participants perceived that they have not been incorporated into medical centres adequately and comprehensively.
• Steps have been taken to encourage health care providers to incorporate standards into practice, including:
o Guidelines for primary care have been developed and collected in a resource book shared with family doctors to encourage incorporation of standards in their practice. However, the development and adaptation of these guidelines were not reviewed or approved by the MOH and activities were completed locally, not nationally.
o In Prizren Regional Hospital, each ambulance has been equipped with a manual as a convenient reference for staff.
• WHO guidelines are used and monitored on a case-by-case basis at institutional and regional levels, based on individual preference. There is no central system for monitoring the utilization of WHO guidelines.
• Lack of awareness of local guidelines.
• Lack of clarity regarding the difference between a clinical protocol and guideline.
• Lack of an evaluation scale or indicators to evaluate action.
• Lack of human resources to consolidate information for a central monitoring system.
• Lack of financial resources to incorporate standards into practice.
• Engaging clinicians who have successfully implemented protocols in their own clinics.
• Scaling up local auditing to monitor the use of clinical guidelines.
In progress:
• A new division in the MOH will be created to monitor and evaluate health services, including monitoring clinical protocols and guidelines.
• Placing protocols in all clinics to encourage their use.
Possible:
• MOH could validate the use of the Effective Perinatal Care (EPC) programme as the national programme and advocate for its use as a basis for adapting national protocols.
• The program could increase the number of inspectors in the MOH and contribute to monitoring and evaluation of implementation, validation and re-validation of health institutions and experts.
#3: Create motivational strategies such as incentives for health care staff (including managers and clinicians) to encourage guideline adherence. • The majority of participants indicated that no motivation or incentive strategies are currently being used.
• Some mentioned modest support of local level incentives, such as motivating trained staff to give seminars/lectures to encourage guideline implementation as part of continuing medical education.
• MOH has drafted a directive which outlines job description, competencies and coefficient of salaries to create more incentives for nurses and midwives, but this has not yet been approved.
• A national level performance-based incentive program is currently in development.
• Barriers to using incentives for health care staff, such as the Payment for Performance (P4P), were identified:
o Causes dissatisfaction among health care workers due to the lack of clear indicators for performance evaluation at individual/ institutional levels;
o Perceived as being subjective and biased;
o Could result in engaging individuals based on their influence on decision making bodies rather than performance;
o Could result in false/over reporting on guideline adherence.
• Difficult to expect adherence to internationally developed guidelines (due to unavailability of nationally developed guidelines) without approval/endorsement by the MOH.
• Lack of clarity regarding the difference between a clinical protocol and guideline.
• Difficult to motivate private practitioners as MOH does not have authority over private practice.
• Presence of a health law (2012) and health insurance law (2014) allows payment based on performance.
• Performance-based payment could motivate health care staff to further develop clinical protocols, implement change and improve quality of health care.
• Luxembourg government provided a monetary donation to encourage guideline adherence among health care workers.
• Participation in maternal and perinatal health care conferences allows for greater involvement in and knowledge of implementing guidelines to address the three most frequent maternal health problems.
In progress:
• The national level performance-based incentive program will be applied in all institutions as part of the action plan and strategies to strengthen the health sector.
Possible:
• In the future, health care workers will have to be relicensed every 5 years, therefore they could be provided with credits and free days for joining working groups for guideline development and adaptation.
#4: Increase communication across stakeholder groups including clinicians, managers, and policymakers through participation in activities such as guideline development committees. • Communication between MOH and clinicians organizations has improved over the past year but only occurs during infrequently organized gatherings/meetings.
• Although no guideline development committee has been developed, some participants identified stakeholders to include in these committees, but are waiting for approval from MOH to proceed.
• Previously established committees have become disengaged due to political circumstances and staffing changes at the MOH; awaiting direction from the MOH to proceed.
• MOH level barriers (e.g., presence of official procedures, formalities, and bureaucracy and lack of decisional authority given to members outside MOH).
• Funding for GDG (guideline development group).
• Participation in guideline development meetings provides opportunities to increase communication across stakeholder groups. • Once established, the development committee can progress with guideline and protocol development.
#5: Create a guideline implementation working group with representative stakeholders at the local level. • A central level guideline implementation working group has been formed for approval but the group is not yet operational.
• The national committee is awaiting administrative instruction to regulate the process of guideline development/adaptation and MOH approval for the guideline development committee.
• FG participants explained how the national committee is waiting for requests to come from clinicians in order to establish the guideline implementation working group.
• In contrast, interview participants explained how an implementation working group has not been created because they are waiting on MOH approval.
• MOH level barriers (e.g., presence of official procedures, formalities, and bureaucracy and lack of decisional authority given to members outside MOH). • No facilitators identified by participants. • Once the guideline development committee is active they can move forward with development of an implementation working group.
#6: Develop a small working group with local representatives from clinician groups, the MOH guidelines committee and quality portfolio, clinical or health services researchers, and the WHO to move forward with implementation. • A small working group has not been created due to road blocks at the MOH level (i.e., waiting for approval for the development committee). • MOH level barriers (e.g., presence of official procedures, formalities, and bureaucracy and lack of decisional authority given to members outside MOH). • No facilitators identified by participants. • No future direction identified by participants.
#7: Consider offering workshops on guideline development methods, including use of GRADE (Guyatt et al., 2008), on appraisal of guidelines using AGREE, and on guidelines adaptation (National Collaborating Centre for Methods and Tools [NCCMT], 2011), for representatives from the MOH and clinical groups. • 3 guideline development training sessions have been offered:
 i. AGREE/ADAPTE Workshop in Kosovo 2013
 ii. UNFPA supported workshop Skopje (Macedonia)
 iii. Suisse Diamonds
• Knowledge gained by workshop participants is being implemented
• Opinions with respect to progress in implementing new practices varied:
o Difficulties cited but positive results observed;
o Trainings partially useful but poor implementation.
• Lack of funds to hold workshop and financially support those interested in attending. • Although no facilitators were identified, participants expressed the utility of the workshops and how they would encourage other health care professionals to attend or be involved in offering future workshops. • Most participants acknowledged the need to send additional staff to obtain guideline training around development and evaluation, but there are no plans to offer further workshops.
• Participation in more frequent workshops could encourage guideline implementation.
#8: Consider engaging some of the local clinicians on the WHO guidelines development group. • Some participants cited that no progress has been made, whereas others indicated that preliminary stages of selecting topics and working group members are underway. • Lack of funds to compensate working group members. • No facilitators identified by participants. • Suggestions for engagement:
o Use credits if relicensing system is introduced;
o Have WHO headquarters send out invitations to join working groups;
o WHO could support members for events like academic conferences and training with financial incentives (10 or 20 euros/ daily expenses) to encourage training and participation.
#9: Engage those interested in guideline development and implementation from neighbouring countries in the workshop activities and create a ‘virtual’ community of practice to share experiences and avoid duplication of effort. • Majority of participants have had meetings and/or trainings to share experiences around common contextual issues. Examples of countries engaged: Albania, Macedonia, Bosnia-Herzegovina, and Serbia.
• A few networks and telemedicine communities have been formed as a communication tool to connect to regional hospitals in real time and share experiences around guideline development.
• WHO State Membership is needed for WHO to recognize Kosovo as a country office.
• Lack of staff/resources to dedicate to activity.
• Lack of clear criteria for selecting group members to join working group, MOH makes final decision.
• Administrative and bureaucratic delays (e.g., moving paper work through the system).
• No language barrier exists for Kosovo and Albania, thus making it easier to set up and maintain a virtual community of practice to share experiences. • The MOH and University Hospital in Tirana (Albania) have guidelines and protocols for nurses/midwives and representatives from Albania could be engaged to share their experience with Kosovo.
• Create a webpage through United Nations Environment Program and have a virtual community.
• Telemedicine can be used as a virtual community.